Provider Demographics
NPI:1801810189
Name:STAATZ, SCOTT DALE (OD)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:DALE
Last Name:STAATZ
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2707 MILLER ST
Mailing Address - Street 2:
Mailing Address - City:BETHANY
Mailing Address - State:MO
Mailing Address - Zip Code:64424-2704
Mailing Address - Country:US
Mailing Address - Phone:660-425-8116
Mailing Address - Fax:660-425-3418
Practice Address - Street 1:2707 MILLER ST
Practice Address - Street 2:
Practice Address - City:BETHANY
Practice Address - State:MO
Practice Address - Zip Code:64424-2704
Practice Address - Country:US
Practice Address - Phone:660-425-8116
Practice Address - Fax:660-425-3418
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOTO3394152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOU61078Medicare UPIN
MONOOA430Medicare ID - Type Unspecified